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Self-Assessment Questions

Critical Care Medicine

Pulmonary Disease in the Intensive Care Unit: Review Questions

Joseph Varon, MD, FACP, FCCP, FCCM, Paul E. Marik, MD, FCCP, FCCM, and Robert E. Fromm, Jr, MD, MPH, FACP, FCCP, FCCM

Dr. Varon is an Associate Professor of Medicine, Baylor College of Medicine, Houston, TX; and a member of the Hospital Physician Editorial Board. Dr. Marik is a Professor of Medicine, Anesthesiology, and Critical Care, University of Pittsburgh, Pittsburgh, PA. Dr. Fromm is an Associate Professor of Medicine, Baylor College of Medicine, Houston, TX.

Choose the single best answer for each question.

1. A patient is receiving supportive therapy in the intensive care unit for acute respiratory distress syndrome (ARDS). On the eighth day of treatment, a bronchoscopic directed protected specimen brushing is performed to evaluate a new infiltrate. Which of the following microorganisms is NOT likely to be isolated?
  1. Haemophilus influenzae
  2. Klebsiella pneumoniae
  3. Prevotella melaninogenica
  4. Pseudomonas aeruginosa
  5. Staphylococcus aureus
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2. A 24-year-old man with asthma is intubated for respiratory failure. The patient is sedated with lorazepam and paralyzed with doxacurium. The initial ventilator settings are as follows: assist/control mode rate, 12 breaths/min; tidal volume, 700 mL; inspiratory flow rate, 90 L/min; positive end-expiratory pressure (PEEP), 0 cm H2O. As the peak airway pressure reaches 53 cm H2O, the flow rate is reduced to 60 L/min with a decrease in the peak airway pressure to 42 cm H2O. Thirty minutes later, the patients blood pressure has decreased from 140/75 to 70/45 mm Hg. Auscultation reveals diminished breath sounds bilaterally with both inspiratory and expiratory rhonchi. Which of the following is the most appropriate next step?

  1. Administer a 500-mL bolus of lactated Ringer’s solution intravenously
  2. Further decrease the inspiratory flow rate
  3. Increase the PEEP to 10 cm H2O
  4. Insert bilateral chest tubes
  5. Reduce the respiratory rate
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3. Which of the following best describes the appearance of a pneumothorax on a radiograph taken with the patient in the supine position?
  1. Apical capping
  2. Apical hyperlucency
  3. Deep sulcus sign
  4. Increased radiolucency of the lung fields
  5. Multiple vertical lucency sign
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4. A patient with ARDS develops refractory hypoxemia despite attempts at various modes of mechanical ventilation. The patient is finally turned and ventilated in the prone position. The PaO2 increases significantly with a fall in the pulmonary admixture ratio. Which of the following best explains the improvement in oxygenation?

  1. Change in regional diaphragmatic movement
  2. Increased functional residual capacity
  3. Increased mobilization of secretions
  4. Increased perfusion to the nondependent ventral lung regions
  5. Increased ventilation to the nondependent ventral lung regions
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